Ophthalmologic Techniques That Evaluate the Posterior Eye Segment

MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

Original Issue Date (Created): 8/9/2002 Most Recent Review Date (Revised): 7/31/2020 Effective Date: 12/1/2020

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

I. POLICY Analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects, multiple sclerosis, increased intracranial pressure, optic neuritis or optic nerve disorders may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography. Analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation for all other indications is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. The measurement of ocular blood flow, pulsatile ocular blood flow or blood flow velocity is considered investigational for all indications. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Cross-references: MP-2.028 Eye Care MP-2.085 Optical Coherence Tomography (OCT) of the Anterior Eye Segment MP-2.086 Retinal Telescreening for Diabetic Retinopathy

II. PRODUCT VARIATIONS Top This policy is only applicable to certain programs and products administered by Capital BlueCross please see additional information below, and subject to benefit variations as discussed in Section VI below. FEP PPO- Refer to FEP Medical Policy Manual MP-9.03.06, Ophthalmologic Techniques for Evaluating Glaucoma. The FEP Medical Policy Manual can be found at: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-management- guidelines/medical-policies.

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

III. DESCRIPTION/BACKGROUND Top Several techniques have been developed to measure the thickness of the optic nerve/retinal nerve fiber layer (RNFL) as a method to diagnose and monitor glaucoma. Measurement of ocular blood flow is also being evaluated as a diagnostic and management tool for glaucoma. GLAUCOMA Glaucoma is characterized by degeneration of the optic nerve (optic disc). Elevated intraocular pressure (IOP) has long been thought to be the primary etiology, but the relation between IOP and optic nerve damage varies among patients, suggesting a multifactorial origin. For example, some patients with clearly elevated IOP will show no optic nerve damage, while others with marginal or no pressure elevation will show optic nerve damage. The association between glaucoma and other vascular disorders (e.g., diabetes, hypertension) suggests vascular factors may play a role in glaucoma. Specifically, it has been hypothesized that reductions in blood flow to the optic nerve may contribute to the visual field defects associated with glaucoma. Diagnosis and Management A comprehensive ophthalmologic exam is required for the diagnosis of glaucoma, but no single test is adequate to establish diagnosis. A comprehensive ophthalmologic examination includes assessment of the optic nerve, evaluation of visual fields, and measurement of ocular pressure. The presence of characteristic changes in the optic nerve or abnormalities in visual field, together with increased IOP, is sufficient for a definitive diagnosis. However, some patients will show ophthalmologic evidence of glaucoma with normal IOPs. These cases of normal tension glaucoma (NTG) are considered to be a type of primary open-angle glaucoma (POAG). Angle- closure glaucoma is another type of glaucoma associated with an increase in IOP. The increased IOP in angle-closure glaucoma arises from a reduction in aqueous outflow from the eye due to a closed angle in the anterior chamber. Diagnosis of angle-closure glaucoma is detailed in MP- 2.085. Conventional management of patients with glaucoma principally involves drug therapy to control elevated IOPs, and serial evaluation of the optic nerve, to follow disease progression. Standard methods of evaluation include careful direct examination of the optic nerve using ophthalmoscopy or stereophotography, or evaluation of visual fields. There is interest in developing more objective, reproducible techniques both to document optic nerve damage and to detect early changes in the optic nerve and retinal nerve fiber layer (RNFL) before the development of permanent visual field deficits. Specifically, evaluating changes in RNFL thickness has been investigated as a technique to diagnose and monitor glaucoma. However, IOP reduction is not effective in decreasing disease progression in a significant number of patients, and in patients with NTG, there is never an increase in IOP. It has been proposed that vascular dysregulation is a significant cause of damage to the RNFL, and there is interest in measuring ocular blood flow as both a diagnostic and a management tool for glaucoma. Changes in blood flow to the retina and choroid may be particularly relevant for diagnosis and treatment of NTG. A variety of techniques have been developed, as described below. (Note: This policy only addresses techniques related to the evaluation of the optic nerve, RNFL, or blood flow to the retina and choroid in patients with glaucoma.)

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

MULTIPLE SCLEROSIS This central nervous system disease involves an immune-mediated process, which directs an abnormal response from the body’s immune system to the central nervous system (the brain, spinal cord and optic nerves). In up to 20% of multiple sclerosis (MS) patients optic neuropathy may be the first demyelinating event. The most common type of involvement of the visual pathways is optic neuritis, which can result in varying degrees of visual loss. OPTIC NEURITIS Inflammation of the optic nerve. Often associated with MS this demyelinating and inflammatory condition occurs in 50% of MS patients and is the presenting feature in 15 to 20 percent of patients. Typically, painful, monocular vision loss evolves over hours to a few days. OCT can detect RNFL thinning in 85% of patients with this condition. PAPILLEDEMA Papilledema is optic disc swelling due to raised intracranial pressure. It occurs when raised intracranial pressure is transmitted to the optic nerve sheath. Typically bilateral, it is often discovered when individuals are evaluated for other symptoms. Visual symptoms are common, although rarely the presenting symptom. Diagnostic testing may include optical coherence tomography both to monitor swelling and to determine changes surrounding the retina. Left untreated vision loss can occur. Techniques to Evaluate the Optic Nerve and RNFL Confocal Scanning Laser Ophthalmoscopy Confocal scanning laser ophthalmoscopy (CSLO) is an image acquisition technique intended to improve the quality of the eye examination compared with standard ophthalmologic examination. A laser is scanned across the retina along with a detector system. Only a single spot on the retina is illuminated at any time, resulting in a high-contrast image of great reproducibility that can be used to estimate RNFL thickness. In addition, this technique does not require maximal mydriasis, which may be problematic in patients with glaucoma. The Heidelberg Retinal Tomograph is probably the most common example of this technology. Scanning Laser Polarimetry The RNFL is birefringent (or biorefractive), meaning that it causes a change in the state of polarization of a laser beam as it passes. A 780-nm diode laser is used to illuminate the optic nerve. The polarization state of the light emerging from the eye is then evaluated and correlated with RNFL thickness. Unlike CSLO, scanning laser polarimetry (SLP) can directly measure the thickness of the RNFL. GDx is a common SLP device. GDx contains a normative database and statistical software package that compare scan results with age-matched normal subjects of the same ethnic origin. The advantages of this system are that images can be obtained without pupil dilation and evaluation can be completed in 10 minutes. Current instruments have added enhanced and variable corneal compensation technology to account for corneal polarization.

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

Optical Coherence Tomography Optical coherence tomography (OCT) uses near-infrared light to provide direct cross-sectional measurement of the RNFL. The principles employed are similar to those used in B-mode ultrasound except light, not sound, is used to produce the 2-dimensional images. The light source can be directed into the eye through a conventional slit-lamp biomicroscope and focused onto the retina through a typical 78-diopter lens. This system requires dilation of the patient’s pupil. OCT analysis software is being developed to include optic nerve head parameters with spectral domain OCT, analysis of macular parameters, and hemodynamic parameters with Doppler OCT and OCT angiography. Pulsatile Ocular Blood Flow The pulsatile variation in ocular pressure results from the flow of blood into the eye during cardiac systole. Pulsatile ocular blood flow can thus be detected by the continuous monitoring of intraocular pressure. The detected pressure pulse can then be converted into a volume measurement using the known relation between ocular pressure and ocular volume. Pulsatile blood flow is primarily determined by the choroidal vessels, particularly relevant to patients with glaucoma, because the optic nerve is supplied in large part by choroidal circulation. Techniques to Measure Ocular Blood Flow A number of techniques have been developed to assess ocular blood flow. They include laser speckle flowgraphy, color Doppler imaging, Doppler Fourier domain OCT, laser Doppler velocimetry, confocal scanning laser Doppler flowmetry, and retinal functional imaging. Laser Speckle Flowgraphy Laser speckle is detected when a coherent light source such as laser light is dispersed from a diffusing surface such as retinal and choroidal vessels and the circulation of the optic nerve head. The varying patterns of light can be used to determine red blood cell velocity and retinal blood flow. However, due to differences in the tissue structure in different eyes, flux values cannot be used for comparisons between eyes. This limitation may be overcome by subtracting background choroidal blood flow results from the overall blood flow results in the region of interest. Color Doppler Imaging Color Doppler imaging has also been investigated as a technique to measure the blood flow velocity in the retinal and choroidal arteries. This technique delivers ultrasound in pulsed Doppler mode with a transducer set on closed eyelids. The examination takes 30 to 40 minutes, and is most effective for the mean velocity of large ophthalmic vessels such as the ophthalmic artery, the central retinal artery, and the short posterior ciliary arteries. However, total blood flow cannot be determined with this technique, and imaging is highly dependent on probe placement. Doppler Fourier Domain OCT Doppler Fourier domain OCT is a noncontact imaging technique that detects the intensity of the light scattered back from erythrocytes as they move in the vessels of the ocular tissue. This induces a frequency shift that represents the velocity of the blood in the ocular tissue.

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

Laser Doppler Velocimetry Laser Doppler velocimetry compares the frequency of reflected laser light from a moving particle to stationary tissue. Confocal Scanning Laser Doppler Flowmetry Confocal scanning laser Doppler flowmetry combines laser Doppler flowmetry with confocal scanning laser tomography. Infrared laser light is used to scan the retina, and the frequency and amplitude of Doppler shifts are determined from the reflected light. Determinations of blood velocity and blood volume are used to compute the total blood flow and create a physical map of retinal flow values. Regulatory Status A number of confocal scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography (OCT) devices have been cleared by the U.S. Food and Drug Administration (FDA) through the 510(k) process for imaging the posterior eye segment. For example, the RTVue XR OCT Avanti™ (Optovue) is an OCT system indicated for the in vivo imaging and measurement of the retina, retinal nerve fiber layer, and optic disc as a tool and aid in the clinical diagnosis and management of retinal diseases. The RTVue XR OCT Avanti™ with Normative Database is a quantitative tool for comparing retina, retinal nerve fiber layer, and optic disk measurements in the human eye to a database of known normal subjects. It is intended as a diagnostic device to aid in the detection and management of ocular diseases. In 2016, the RTVue XR OCT with Avanti™ with AngioVue™ Software was cleared by FDA through the 510(k) process (K153080) as an aid in the visualization of vascular structures of the retina and choroid. FDA product code: HLI, OBO. In 2012, the iExaminer™ (Welch Allyn) was cleared for marketing by FDA through the 510(k) process. The iExaminer™ consists of a hardware adapter and associated software (iPhone® App) to capture, store, send, and retrieve images from the PanOptic™ Ophthalmoscope (Welch Allyn) using an iPhone®. FDA product code: HKI.

IV. RATIONALE Top SUMMARY OF EVIDENCE For individuals who have glaucoma or suspected glaucoma who receive imaging of the optic nerve and retinal nerve fiber layer, the evidence includes studies on diagnostic accuracy. Relevant outcomes are test accuracy, symptoms, morbid events, functional outcomes, and medication use. Confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) can be used to evaluate the optic nerve and retinal nerve fiber layer in patients with glaucoma and suspected glaucoma. Numerous articles have described findings from patients with known and suspected glaucoma using CSLO, SLP, and OCT. These studies have reported that abnormalities may be detected on these examinations before functional changes are noted. The literature and specialty society guidelines have indicated that optic nerve analysis using CSLO, SLP, and OCT are established add-on tests that

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

may be used to diagnose and manage patients with glaucoma and suspected glaucoma. These results are often considered along with other findings to make diagnostic and therapeutic decisions about glaucoma care, including use of topical medication, monitoring, and surgery to lower intraocular pressure. Thus, accurate diagnosis of glaucoma would be expected to reduce the progression of glaucoma. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who have glaucoma or suspected glaucoma who receive evaluation of ocular blood flow, the evidence includes association studies. Relevant outcomes are test accuracy, symptoms, morbid events, functional outcomes, and medication use. Techniques to measure ocular blood flow or ocular blood velocity are used to determine appropriate glaucoma treatment options. The data for these techniques remain limited. Literature reviews have not identified studies on the technical performance of these tests (e.g., test-retest reliability), whether these technologies improve diagnostic accuracy, or whether they improve health outcomes in patients with glaucoma. Some have suggested that these parameters may inform understanding of the variability in visual field changes in patients with glaucoma, i.e., they may help explain why patients with similar levels of intraocular pressure develop markedly different visual impairments. However, data on use of ocular blood flow, pulsatile ocular blood flow, and/or blood flow velocity are currently lacking. The evidence is insufficient to determine the effects of the technology on health outcomes.

V. DEFINITIONS Top CUP/DISC RATIO in ophthalmology is the mathematic relationship between the horizontal or vertical diameter of the physiologic cup and the diameter of the optic disc. DIABETIC RETINOPATHY is a disorder of retinal blood vessels characterized by capillary microaneurysms, hemorrhage, exudates, and the formation of new vessels and connective tissue. INTRAOCULAR PRESSURE refers to the internal pressure of the eye regulated by resistance to the flow of aqueous humor through the fine sieve of the trabecular meshwork. VI. BENEFIT VARIATIONS Top The existence of this medical policy does not mean that this service is a covered benefit under the member's health benefit plan. Benefit determinations should be based in all cases on the applicable health benefit plan language. Medical policies do not constitute a description of benefits. A member’s health benefit plan governs which services are covered, which are excluded, which are subject to benefit limits and which require preauthorization. There are different benefit plan designs in each product administered by Capital BlueCross. Members and providers should consult the member’s health benefit plan for information or contact Capital BlueCross for benefit information.

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

VII. DISCLAIMER Top Capital BlueCross’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member’s benefit information, the benefit information will govern. If a provider or a member has a question concerning the application of this medical policy to a specific member’s plan of benefits, please contact Capital BlueCross’ Provider Services or Member Services. Capital BlueCross considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law.

VIII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

ICD-10-CM Diagnosis Description Codes G35 Multiple sclerosis G93.2 Benign intracranial hypertension H40.001 Preglaucoma, unspecified, right eye H40.002 Preglaucoma, unspecified, left eye H40.003 Preglaucoma, unspecified, bilateral H40.011 Open angle with borderline findings, low risk, right eye H40.012 Open angle with borderline findings, low risk, left eye H40.013 Open angle with borderline findings, low risk, bilateral H40.021 Open angle with borderline findings, high risk, right eye H40.022 Open angle with borderline findings, high risk, left eye H40.023 Open angle with borderline findings, high risk, bilateral H40.029 Open angle with borderline findings, high risk, unspecified eye

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H40.031 Anatomical narrow angle, right eye H40.032 Anatomical narrow angle, left eye H40.033 Anatomical narrow angle, bilateral H40.039 Anatomical narrow angle, unspecified eye H40.041 Steroid responder, right eye H40.042 Steroid responder, left eye H40.043 Steroid responder, bilateral H40.049 Steroid responder, unspecified eye H40.051 Ocular hypertension, right eye H40.052 Ocular hypertension, left eye H40.053 Ocular hypertension, bilateral H40.059 Ocular hypertension, unspecified eye H40.061 Primary angle closure without glaucoma damage, right eye H40.062 Primary angle closure without glaucoma damage, left eye H40.063 Primary angle closure without glaucoma damage, bilateral H40.069 Primary angle closure without glaucoma damage, unspecified eye H40.1111 Primary open-angle glaucoma, right eye, mild stage H40.1112 Primary open-angle glaucoma, right eye, moderate stage H40.1113 Primary open-angle glaucoma, right eye, severe stage H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage H40.1120 Primary open-angle glaucoma, left eye, stage unspecified H40.1121 Primary open-angle glaucoma, left eye, mild stage H40.1122 Primary open-angle glaucoma, left eye, moderate stage H40.1123 Primary open-angle glaucoma, left eye, severe stage H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified H40.1131 Primary open-angle glaucoma, bilateral, mild stage H40.1132 Primary open-angle glaucoma, bilateral, moderate stage H40.1133 Primary open-angle glaucoma, bilateral, severe stage H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage H40.1190 Primary open-angle glaucoma, unspecified eye, stage unspecified H40.1191 Primary open-angle glaucoma, unspecified eye, mild stage H40.1192 Primary open-angle glaucoma, unspecified eye, moderate stage H40.1193 Primary open-angle glaucoma, unspecified eye, severe stage H40.1194 Primary open-angle glaucoma, unspecified eye, indeterminate stage H40.1210 Low-tension glaucoma, right eye, stage unspecified H40.1211 Low-tension glaucoma, right eye, mild stage

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H40.1212 Low-tension glaucoma, right eye, moderate stage H40.1213 Low-tension glaucoma, right eye, severe stage H40.1214 Low-tension glaucoma, right eye, indeterminate stage H40.1220 Low-tension glaucoma, left eye, stage unspecified H40.1221 Low-tension glaucoma, left eye, mild stage H40.1222 Low-tension glaucoma, left eye, moderate stage H40.1223 Low-tension glaucoma, left eye, severe stage H40.1224 Low-tension glaucoma, left eye, indeterminate stage H40.1230 Low-tension glaucoma, bilateral, stage unspecified H40.1231 Low-tension glaucoma, bilateral, mild stage H40.1232 Low-tension glaucoma, bilateral, moderate stage H40.1233 Low-tension glaucoma, bilateral, severe stage H40.1234 Low-tension glaucoma, bilateral, indeterminate stage H40.1290 Low-tension glaucoma, unspecified eye, stage unspecified H40.1291 Low-tension glaucoma, unspecified eye, mild stage H40.1292 Low-tension glaucoma, unspecified eye, moderate stage H40.1293 Low-tension glaucoma, unspecified eye, severe stage H40.1294 Low-tension glaucoma, unspecified eye, indeterminate stage H40.1310 Pigmentary glaucoma, right eye, stage unspecified H40.1311 Pigmentary glaucoma, right eye, mild stage H40.1312 Pigmentary glaucoma, right eye, moderate stage H40.1313 Pigmentary glaucoma, right eye, severe stage H40.1314 Pigmentary glaucoma, right eye, indeterminate stage H40.1320 Pigmentary glaucoma, left eye, stage unspecified H40.1321 Pigmentary glaucoma, left eye, mild stage H40.1322 Pigmentary glaucoma, left eye, moderate stage H40.1323 Pigmentary glaucoma, left eye, severe stage H40.1324 Pigmentary glaucoma, left eye, indeterminate stage H40.1330 Pigmentary glaucoma, bilateral, stage unspecified H40.1331 Pigmentary glaucoma, bilateral, mild stage H40.1332 Pigmentary glaucoma, bilateral, moderate stage H40.1333 Pigmentary glaucoma, bilateral, severe stage H40.1334 Pigmentary glaucoma, bilateral, indeterminate stage H40.1390 Pigmentary glaucoma, unspecified eye, stage unspecified H40.1391 Pigmentary glaucoma, unspecified eye, mild stage H40.1392 Pigmentary glaucoma, unspecified eye, moderate stage H40.1393 Pigmentary glaucoma, unspecified eye, severe stage

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H40.1394 Pigmentary glaucoma, unspecified eye, indeterminate stage H40.1410 Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified H40.1411 Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H40.1412 Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage H40.1413 Capsular glaucoma with pseudoexfoliation of lens, right eye, severe stage H40.1414 Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage H40.1420 Capsular glaucoma with pseudoexfoliation of lens, left eye, stage unspecified H40.1421 Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H40.1422 Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H40.1423 Capsular glaucoma with pseudoexfoliation of lens, left eye, severe stage H40.1424 Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage H40.1430 Capsular glaucoma with pseudoexfoliation of lens, bilateral, stage unspecified H40.1431 Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H40.1432 Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage H40.1433 Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage H40.1434 Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage H40.211 Acute angle-closure glaucoma, right eye H40.212 Acute angle-closure glaucoma, left eye H40.213 Acute angle-closure glaucoma, bilateral H40.2211 Chronic angle-closure glaucoma, right eye, mild stage H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage H40.2213 Chronic angle-closure glaucoma, right eye, severe stage H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage H40.2220 Chronic angle-closure glaucoma, left eye, stage unspecified H40.2221 Chronic angle-closure glaucoma, left eye, mild stage H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage H40.2223 Chronic angle-closure glaucoma, left eye, severe stage H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage H40.2230 Chronic angle-closure glaucoma, bilateral, stage unspecified H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage H40.31X0 Glaucoma secondary to eye trauma, right eye, stage unspecified H40.31X1 Glaucoma secondary to eye trauma, right eye, mild stage H40.31X2 Glaucoma secondary to eye trauma, right eye, moderate stage H40.31X3 Glaucoma secondary to eye trauma, right eye, severe stage

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H40.31X4 Glaucoma secondary to eye trauma, right eye, indeterminate stage H40.32X0 Glaucoma secondary to eye trauma, left eye, stage unspecified H40.32X1 Glaucoma secondary to eye trauma, left eye, mild stage H40.32X2 Glaucoma secondary to eye trauma, left eye, moderate stage H40.32X3 Glaucoma secondary to eye trauma, left eye, severe stage H40.32X4 Glaucoma secondary to eye trauma, left eye, indeterminate stage H40.33X0 Glaucoma secondary to eye trauma, bilateral, stage unspecified H40.33X1 Glaucoma secondary to eye trauma, bilateral, mild stage H40.33X2 Glaucoma secondary to eye trauma, bilateral, moderate stage H40.33X3 Glaucoma secondary to eye trauma, bilateral, severe stage H40.33X4 Glaucoma secondary to eye trauma, bilateral, moderate stage H40.41X0 Glaucoma secondary to eye inflammation, right eye, stage unspecified H40.41X1 Glaucoma secondary to eye inflammation, right eye, mild stage H40.41X2 Glaucoma secondary to eye inflammation, right eye, moderate stage H40.41X3 Glaucoma secondary to eye inflammation, right eye, severe stage H40.41X4 Glaucoma secondary to eye inflammation, right eye, indeterminate stage H40.42X0 Glaucoma secondary to eye inflammation, left eye, stage unspecified H40.42X1 Glaucoma secondary to eye inflammation, left eye, mild stage H40.42X2 Glaucoma secondary to eye inflammation, left eye, moderate stage H40.42X3 Glaucoma secondary to eye inflammation, left eye, severe stage H40.42X4 Glaucoma secondary to eye inflammation, left eye, indeterminate stage H40.43X0 Glaucoma secondary to eye inflammation, bilateral, stage unspecified H40.43X1 Glaucoma secondary to eye inflammation, bilateral, mild stage H40.43X2 Glaucoma secondary to eye inflammation, bilateral, moderate stage H40.43X3 Glaucoma secondary to eye inflammation, bilateral, severe stage H40.43X4 Glaucoma secondary to eye inflammation, bilateral, indeterminate stage H40.51X0 Glaucoma secondary to other eye disorders, right eye, stage unspecified H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage H40.52X0 Glaucoma secondary to other eye disorders, left eye, stage unspecified H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage H40.53X0 Glaucoma secondary to other eye disorders, bilateral, stage unspecified

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage H40.61X0 Glaucoma secondary to drugs, right eye, stage unspecified H40.61X1 Glaucoma secondary to drugs, right eye, mild stage H40.61X2 Glaucoma secondary to drugs, right eye, moderate stage H40.61X3 Glaucoma secondary to drugs, right eye, severe stage H40.61X4 Glaucoma secondary to drugs, right eye, indeterminate stage H40.62X0 Glaucoma secondary to drugs, left eye, stage unspecified H40.62X1 Glaucoma secondary to drugs, left eye, mild stage H40.62X2 Glaucoma secondary to drugs, left eye, moderate stage H40.62X3 Glaucoma secondary to drugs, left eye, severe stage H40.62X4 Glaucoma secondary to drugs, left eye, indeterminate stage H40.63X0 Glaucoma secondary to drugs, bilateral, stage unspecified H40.63X1 Glaucoma secondary to drugs, bilateral, mild stage H40.63X2 Glaucoma secondary to drugs, bilateral, moderate stage H40.63X3 Glaucoma secondary to drugs, bilateral, severe stage H40.63X4 Glaucoma secondary to drugs, bilateral, indeterminate stage H40.811 Glaucoma with increased episcleral venous pressure, right eye H40.812 Glaucoma with increased episcleral venous pressure, left eye H40.813 Glaucoma with increased episcleral venous pressure, bilateral H40.819 Glaucoma with increased episcleral venous pressure, unspecified eye H40.821 Hypersecretion glaucoma, right eye H40.822 Hypersecretion glaucoma, left eye H40.823 Hypersecretion glaucoma, bilateral H40.829 Hypersecretion glaucoma, unspecified eye H40.831 Aqueous misdirection, right eye H40.832 Aqueous misdirection, left eye H40.833 Aqueous misdirection, bilateral H40.839 Aqueous misdirection, unspecified eye H40.89 Other specified glaucoma H42 Glaucoma in disease classified elsewhere H46.00 Optic papillitis, unspecified eye H46.01 Optic papillitis, right eye H46.02 Optic papillitis, left eye H46.03 Optic papillitis, bilateral eye

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H46.10 Retrobulbar neuritis, unspecified eye H46.11 Retrobulbar neuritis, right eye H46.12 Retrobulbar neuritis, left eye H46.13 Retrobulbar neuritis, bilateral eye H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.8 Other optic neuritis H46.9 Unspecified optic neuritis H47.011 Ischemic optic neuropathy, right eye H47.012 Ischemic optic neuropathy, left eye H47.013 Ischemic optic neuropathy, bilateral eye H47.019 Ischemic optic neuropathy, unspecified eye H47.021 Hemorrhage in optic nerve sheath, right eye H47.022 Hemorrhage in optic nerve sheath, left eye H47.023 Hemorrhage in optic nerve sheath, bilateral eye H47.029 Hemorrhage in optic nerve sheath, unspecified eye H47.031 Optic nerve hypoplasia, right eye H47.032 Optic nerve hypoplasia, left eye H47.033 Optic nerve hypoplasia, bilateral eye H47.039 Optic nerve hypoplasia, unspecified eye H47.091 Other disorders of optic nerve, not elsewhere classified, right eye H47.092 Other disorders of optic nerve, not elsewhere classified, left eye H47.093 Other disorders of optic nerve, not elsewhere classified, bilateral eye H47.099 Other disorders of optic nerve, not elsewhere classified, unspecified eye H47.10 Unspecified papilledema H47.11 Papilledema associated with increased intracranial pressure H47.12 Papilledema associated with decreased ocular pressure H47.13 Papilledema associated with retinal disorder H47.141 Foster-Kennedy syndrome, right eye H47.142 Foster-Kennedy syndrome, left eye H47.143 Foster-Kennedy syndrome, bilateral eye H47.149 Foster-Kennedy syndrome, unspecified eye H47.20 Unspecified optic atrophy H47.211 Primary optic atrophy, right eye H47.212 Primary optic atrophy, left eye H47.213 Primary optic atrophy, bilateral eye H47.219 Primary optic atrophy, unspecified eye

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MEDICAL POLICY

POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR E YE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H47.22 Hereditary optic atrophy H47.231 Glaucomatous optic atrophy, right eye H47.232 Glaucomatous optic atrophy, left eye H47.233 Glaucomatous optic atrophy, bilateral eye H47.239 Glaucomatous optic atrophy, unspecified eye H47.291 Other optic atrophy, right eye H47.292 Other optic atrophy, left eye H47.293 Other optic atrophy, bilateral eye H47.299 Other optic atrophy, unspecified eye H47.311 Coloboma of optic disc, right eye H47.312 Coloboma of optic disc, left eye H47.313 Coloboma of optic disc, bilateral eye H47.319 Coloboma of optic disc, unspecified eye H47.321 Drusen of optic disc, right eye H47.322 Drusen of optic disc, left eye H47.323 Drusen of optic disc, bilateral eye H47.329 Drusen of optic disc, unspecified eye H47.331 Pseudopapilledema of optic disc, right eye H47.332 Pseudopapilledema of optic disc, left eye H47.333 Pseudopapilledema of optic disc, bilateral eye H47.339 Pseudopapilledema of optic disc, unspecified eye H47.391 Other disorders of optic disc, right eye H47.392 Other disorders of optic disc, left eye H47.393 Other disorders of optic disc, bilateral eye H47.399 Other disorders of optic disc, unspecified eye H47.41 Disorders of optic chiasm in (due to) inflammatory disorders H47.42 Disorders of optic chiasm in (due to) neoplasm H47.43 Disorders of optic chiasm in (due to) vascular disorders H47.49 Disorders of optic chiasm in (due to) other disorders H47.511 Disorders of visual pathways in (due to) inflammatory disorders, right side H47.512 Disorders of visual pathways in (due to) inflammatory disorders, left side H47.519 Disorders of visual pathways in (due to) inflammatory disorders, unspecified side H47.521 Disorders of visual pathways in (due to) neoplasm, right side H47.522 Disorders of visual pathways in (due to) neoplasm, left side H47.529 Disorders of visual pathways in (due to) neoplasm, unspecified side H47.531 Disorders of visual pathways in (due to) vascular disorders, right side H47.532 Disorders of visual pathways in (due to) vascular disorders, left side

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POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

ICD-10-CM Diagnosis Description Codes H47.539 Disorders of visual pathways in (due to) vascular disorders, unspecified side H47.611 Cortical blindness, right side of brain H47.612 Cortical blindness, left side of brain H47.619 Cortical blindness, unspecified side of brain H47.621 Disorders of visual cortex in (due to) inflammatory disorders, right side of brain H47.622 Disorders of visual cortex in (due to) inflammatory disorders, left side of brain H47.629 Disorders of visual cortex in (due to) inflammatory disorders, unspecified side of brain H47.631 Disorders of visual cortex in (due to) neoplasm, right side of brain H47.632 Disorders of visual cortex in (due to) neoplasm, left side of brain H47.639 Disorders of visual cortex in (due to) neoplasm, unspecified side of brain H47.641 Disorders of visual cortex in (due to) vascular disorders, right side of brain H47.642 Disorders of visual cortex in (due to) vascular disorders, left side of brain H47.649 Disorders of visual cortex in (due to) vascular disorders, unspecified side of brain H47.9 Unspecified disorder of visual pathways Q15.0 Congenital Glaucoma Z01.01 Encounter for examination of eyes and vision with abnormal findings

IX. REFERENCES Top 1. Mohindroo C, Ichhpujani P, Kumar S. Current imaging modalities for assessing ocular blood flow in glaucoma. J Curr Glaucoma Pract. Sep-Dec 2016;10(3):104-112. PMID 27857490. 2. Blue Cross and Blue Shield Technology Evaluation Center (TEC). Retinal nerve fiber analysis for the diagnosis and management of glaucoma. TEC Assessments. 2001;Volume 16:Tab 13. 3. Blue Cross and Blue Shield Technology Evaluation Center (TEC). Retinal nerve fiber layer analysis for the diagnosis and management of glaucoma. TEC Assessments. 2003;Volume 18:Tab 7. 4. Ervin AM, Boland MV, Myrowitz EH, et al. Screening for Glaucoma: Comparative Effectiveness (Comparative Effectiveness Review No. 59). Rockville, MD: Agency for Healthcare Research and Quality; 2012. 5. Michelessi M, Lucenteforte E, Oddone F, et al. Optic nerve head and fibre layer imaging for diagnosing glaucoma. Cochrane Database Syst Rev. Nov 30 2015(11):CD008803. PMID 26618332. 6. Lin SC, Singh K, Jampel HD, et al. Optic nerve head and retinal nerve fiber layer analysis: a report by the American Academy of Ophthalmology. Ophthalmology. Oct 2007;114(10)1937- 1949. PMID 17908595.

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POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

7. Shiga Y, Omodaka K, Kunikata H, et al. Waveform analysis of ocular blood flow and the early detection of normal tension glaucoma. Invest Ophthalmol Vis Sci. Nov 2013;54(12):7699- 7706. PMID 24130177. 8. Bafa M, Lambrinakis I, Dayan M, et al. Clinical comparison of the measurement of the IOP with the ocular blood flow tonometer, the Tonopen XL and the Goldmann applanation tonometer. Acta Ophthalmol Scand. Feb 2001;79(1):15-18. PMID 11167279. 9. Schmidl D, Garhofer G, Schmetterer L. The complex interaction between ocular perfusion pressure and ocular blood flow - relevance for glaucoma. Exp Eye Res. Aug 2011;93(2):141- 155. PMID 20868686. 10. Harris A, Kagemann L, Ehrlich R, et al. Measuring and interpreting ocular blood flow and metabolism in glaucoma. Can J Ophthalmol. Jun 2008;43(3):328-336. PMID 18443609. 11. Abegao Pinto L, Willekens K, Van Keer K, et al. Ocular blood flow in glaucoma - the Leuven Eye Study. Acta Ophthalmol. Sep 2016;94(6):592-598. PMID 26895610. 12. Kurysheva NI, Parshunina OA, Shatalova EO, et al. Value of structural and hemodynamic parameters for the early detection of primary open-angle glaucoma. Curr Eye Res. Mar 2017;42(3):411-417. PMID 27341295. 13. Witkowska KJ, Bata AM, Calzetti G, et al. Optic nerve head and retinal blood flow regulation during isometric exercise as assessed with laser speckle flowgraphy. PLoS One. Sep 12 2017;12(9):e0184772. PMID 28898284. 14. Rusia D, Harris A, Pernic A, et al. Feasibility of creating a normative database of colour Doppler imaging parameters in glaucomatous eyes and controls. Br J Ophthalmol. Sep 2011;95(9):1193-1198. PMID 21106991. 15. Calvo P, Ferreras A, Polo V, et al. Predictive value of retrobulbar blood flow velocities in glaucoma suspects. Invest Ophthalmol Vis Sci. Jun 2012;53(7):3875-3884. PMID 22589447. 16. American Academy of Ophthalmology. Preferred Practice Pattern: Primary open-angle suspect. 2015; http://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf. Accessed April 21, 2020. 17. American Academy of Ophthalmology. Preferred Practice Pattern: Primary open-angle glaucoma. 2015; http://www.aaojournal.org/article/S0161-6420(15)01276-2/pdf. Accessed April 21, 2020. 18. Iorga RE, Moraru A, Ozturk MR, Costin D. The role of Optical Coherence Tomography in optic neuropathies. Rom J Ophthalmol. 2018;62(1):3-14.

19. Lamirel C, Newman NJ, Biousse V. Optical coherence tomography (OCT) in optic neuritis and multiple sclerosis. Rev Neurol (Paris). 2010;166(12):978-986. doi:10.1016/j.neurol.2010.03.024

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POLICY NUMBER MP-2.056

20. Mollan SP, Davies B, Silver NC, et al. Idiopathic intracranial hypertension: consensus guidelines on management. Journal of Neurology, Neurosurgery & Psychiatry. 2018;89:1008-1110.

21. Albrecht P, Blasberg C, Ringelstein M, et al. Optical coherence tomography for the diagnosis and monitoring of idiopathic intracranial hypertension. J Neurol. 2017;264(7):1370-1380. doi:10.1007/s00415-017-8532-x

22. Scott CJ, Kardon RH, Lee AG., et al. Diagnosis and grading of papilledema in patients with raised intracranial pressure using optical coherence tomography vs clinical expert assessment using a clinical staging scale. Archives of Ophthalmology. 128.6 (2010): 705- 711. doi:10.1001/archophthalmol.2010.94

23. Malhotra K, Padungkiatsagul T, Moss HE. Optical coherence tomography use in idiopathic intracranial hypertension. Ann Eye Sci. 2020;5:7. doi:10.21037/aes.2019.12.06

24. Bienfang D. Overview and differential diagnosis of papilledema. In: UpToDate. Brazis, P (Ed). UpToDate. Waltham, MA. Accessed July 31, 2020.

25. Olek MJ, Narayan RN, Frohman EM, et al. Manifestations of Multiple Sclerosis in Adults. In: UpToDate. Gonzalez-Scarano F, (Ed). UpToDate. Waltham, MA. Accessed July 31, 2020.

26. Osbone, B, Balcer L. Optic Neuritis: Pathophysiology, clinical feature, and diagnosis. In: UpToDate. Gonzalez-Scarano F, (Ed). UpToDate. Waltham, MA. Accessed July 31, 2020.

27. Blue Cross Blue Shield Association Medical Policy Reference Manual. 9.03.06, Ophthalmic Techniques that Evaluate the Posterior Segment for Glaucoma. April 2020.

X. POLICY HISTORY Top MP 2.056 CAC 12/2/03 CAC 11/30/04 CAC 9/13/05 CAC 11/29/05 CAC 11/28/06 CAC 9/25/07 CAC 7/29/08 CAC 11/25/08 CAC 11/24/09 Consensus List CAC 10/25/11 Adopt BCBSA for Ophthalmologic Techniques for Evaluating Glaucoma. Title changed. Description of stages of glaucoma deleted. Information regarding use of optical coherence tomography (OCT) was differentiated. This policy addresses use of OCT

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POLICY TITLE OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR EYE SEGMENT

POLICY NUMBER MP-2.056

for analysis of the optic nerve only. Reference to new policy MP 2.085 Anterior Eye Segment Optical Imaging added which addresses OCT for anterior eye segment evaluation. Information related to retinal telescreening extracted from this policy and a new policy created MP 2.086 Retinal Telescreening for Diabetic Retinopathy was created. Information related to extended ophthalmoscopy exam deleted. Slight wording change to policy statement related to ophthalmologic techniques for evaluating glaucoma does not change intent of policy. Remains medically necessary. Added Medicare variation to LCD L27504 Non-Invasive Cerebrovascular Arterial Studies for doppler ultrasonography. CAC 10/30/12 Consensus review. No change to policy statements. References updated. Changed FEP variation to reference MP-9.03.06 Ophthalmologic Techniques for Evaluating Glaucoma. Deleted Medicare variation. Coverage criteria matches or current CBC policy is more generous. Codes reviewed. 10/31/12 CAC 11/26/13 Consensus review. References updated, but no changes to the policy statements. CAC 11/25/14 Consensus review. No change to policy statements. References updated. Rationale added. Coding reviewed and ICD 10 ranged coding 11/07/2014. CAC 11/24/15 Consensus review. No change to the policy statements. Reference and rationale update. LCD changed from L27529 to L35038 as part of the LCD ICD-10 update. CAC 11/29/16 Consensus review. No change to policy statements. Variation reformatting completed. Description/Background, Rationale and Reference sections updated. Coding reviewed/updated. 6/1/17 Medicare update – Added a variation to LCD L35038. 1/17/18 Administrative update. Medicare variations removed from Commercial Policies effective 1/1/18. CAC 1/30/18 Minor revision. Doppler ultrasonography removed from the second policy statement. However, the intent of the policy statement is unchanged. Title changed to “Ophthalmologic Techniques That Evaluate the Posterior Eye Segment for Glaucoma.” Description/Background, Rationale and Reference sections updated. 5/16/18 Minor revision. Investigational statement expanded to “all other indications”. Coding review. 3/28/19 Consensus review. Policy statement unchanged. References updated. 10/1/19 Administrative update. Coding review. Diagnosis updated. 1/1/20 Administrative update. New codes 92201 and 92202 added. 4/21/20 Consensus review. Policy statement unchanged. Removed procedure codes 92201 and 92202, references updated. 7/31/20 Major review. Added multiple sclerosis, increased intracranial pressure, optic neuritis and optic nerve disorders to policy statement as potentially medically necessary. Coding updated, added ICD10 codes H46-H47, G35 and G93.2. References updated. “for Glaucoma” removed from policy title.

Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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